An interventional strategy to strengthen integration of NLEP into primary health care

The Government of Orissa implemented the Revised Operational Strategy in September 1999 to integrate the NLEP functions into primary health care activities. An interventional strategy, in the form of consensus on job responsibilities and capacity-building through training of PHC staff, was developed and adopted in a rural block under the Department of Community Medicine to strengthen the integration process. The impact was studied six months after the intervention by comparing it with the leprosy situation in the pre-intervention period. Data were collected by verification of registers at the block PHC and sub-centre levels. Analysis was done using different leprosy indices, such as new case-detection rate (NCDR), child rate, deformity rate, profile of leprosy cases and patient compliance, etc. This integrated approach was found to be more community-oriented and effective in early case-detection in children and women. It also helped in providing continuous MDT services because of the involvement of primary health care functionaries in the post-intervention period.     

Study on integration of the National Leprosy Eradication Programme into primary health care services: a pilot project

The Central Leprosy Training and Research Institute, Chengalpattu, Tamil Nadu, undertook an interventional study, as a pilot project, on integration of the National Leprosy Eradication Programme (NLEP) vertical activities into the PHC system in two selected districts of Visakhapatnam and Krishna of Andhra Pradesh, between September 1997 and March 1999. The objective of the study was to assess the various operational aspects and implications of integrated implementation of the activities of the NLEP through the PHC system. 1,304,163 people (239,142 in the study group and 1,065,020 in the control group) were enrolled in the study. The methodology employed in carrying out the pilot project in the two selected districts is described. MDT was in operation for more than 5 years in these two districts through vertical approach. Prevalence has declined from >50/10000 at the start of MDT to about 3/10000 at the start of the project. During the implementation phase, 1459 new leprosy cases were detected (NCDR 5.39/10000 person-years) and 1458 cases were released from treatment (RFT rate: 93.04%) and towards the end of the project 450 cases were under treatment (PR 1.66/10000). Simple rates, ratios and proportions were used in the analysis of data and results were compared. The interventional study was designed to assess the implications and impact of implementation of NLEP activities through PHC staff. The study design, rationale, data collection, data processing, quality control methods employed in the study project and the results are discussed. The results of the study indicate that integrated implementation of the NLEP by PHC staff is feasible, if proper support is provided.     

Integration of leprosy into GHS in India: a follow up study (2006-2007)

In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006-2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12(66.7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in Andhra Pradesh (6.9 and 22.4%), Madhya Pradesh (26.3 and 14.5%), Rajasthan (19.7 and 40.9%) and Kerala (25.5 and 65.7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38.0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.     

Multidrug therapy in leprosy can prevent relapse--a retrospective study

A retrospective study was done at the Leprosy Control Unit (LCU) in Durgapur of Burdwan district, West Bengal, to determine the relapse rate following multidrug therapy (MDT). A total of 1581 patients (1276 PB and 305 MB) completed MDT regimens during a period of 5 years as per WHO recommendations and National Leprosy Eradication Programme (NLEP) guidelines. The treated patients were kept under surveillance as per NLEP guidelines and searched for relapses. The results of MDT were compared with those of pre-MDT (monotherapy) era at the same centre (total: 405 patients; PB-373, MB-32) and also with those of the Leprosy Clinic in Gopalpur (only dapsone was given to a total of 189 patients, PB-167, MB-22). Following monotherapy, the relapse rate was 10.06% at the Gopalpur Leprosy Clinic and 12.4% at the Durgapur LCU during the 2 years (PB) and 5 years (MB) of surveillance, whereas following MDT no relapse case was encountered both in PB and MB cases during the surveillance periods recommended by WHO. The results of this study are comparable with those of other studies. Though a few studies showed relapses during long-term surveillance beyond the periods recommended by WHO, it is once again established that MDT can prevent relapse in leprosy.     

"Instant" new leprosy case-detection: an experience in Bihar State in India

The National Leprosy Eradication Programme (NLEP) is based on survey, education and treatment, including coverage of all the registered cases with multi-drug therapy (MDT). The Government of India introduced MDT in all leprosy endemic districts through a vertical set-up, and through mobile leprosy treatment units in low endemic districts. Anti-leprosy work has not been uniform in all the states and needed push-start in some, such as Bihar. There have been spurts of leprosy elimination activities and the entire populations of the regions have not been covered because of various administrative reasons and logistic problems. In Singhbhum district of Bihar, a successful attempt was made to cover the maximum population by campaign approach. The strategy was to involve all the field workers of the leprosy programme in the district, supported by a small group of experienced personnel. The campaign, lasting for 39 working days, resulted in detecting leprosy cases equivalent to 64% of cases detected during the previous one full year. The entire operation helped the local staff to gain experience that would be useful for the future of the NLEP, and also provide an insight into working practices. Similar campaign approach can be used in situations where case-detection activities are feeble and the implementation of MDT is slow. If such campaigns are repeated at appropriate intervals, it will be a great support to achieving the goal of leprosy elimination.     

Integration of the leprosy programme into primary health care: a case study of perceptions of primary health care workers

Integration of the vertical leprosy programme into the existing horizontal health programme poses various administrative and operational challenges to programmers. In order to understand the preparedness of the PHC workers for integration of leprosy into primary health care services, 71 PHC workers were interviewed using a structured interview schedule. The results showed that about 42% of the staff have heard of the concept of integration earlier and 90% of the PHC staff are willing to treat leprosy patients in the primary health care centre, but only 72% were in favour of integration. The reasons for favouring integration were (1) wider coverage with MDT, (2) frequent field visits by the worker, (3) better rapport with the community, (4) timely treatment and (5) cost-effectiveness. About 28% of the staff members did not favour integration for the reasons that the leprosy programme would suffer, targets cannot be met, supervision would be difficult, knowledge of the staff was inadequate and importance cannot be given to leprosy as family planning is always a priority in PHC centres. About 43% of the staff felt that the performance of the leprosy programme would be better after integration. With regard to workload, 60% of the sample felt that there would be increase in the workload in the field, record maintenance and supervision. The difficulties foreseen by the workers were grouped into 6 categories, viz., administrative, managerial, technical, personnel, social and miscellaneous. It is worth noting that 91% of the staff that included all categories said they were not afraid of leprosy, but needed training in leprosy work. About 50% of the staff expected increase in salaries and promotions if integration took place.     

Leprosy control in Zimbabwe: from a vertical to a horizontal programme

In Zimbabwe leprosy control services were re-established in 1983, following the war of independence. Its main objectives were the nation-wide implementation of multiple drug treatment (MDT) and the integration of leprosy control into the general health services. The MDT regimens have led to a rapid reduction of the prevalence of leprosy. At the beginning of 1989 357 patients were on treatment and 1299 under follow-up. Six hundred and twenty-seven new cases have been detected since 1984, which represents an annual case detection rate of 1.6 per 100,000. This seems a fair reflection of the incidence rate, as the new cases are characterized by a minority of patients under the age of 15 (4%) and a lepromatous percentage of 50%. As the budget of the programme has remained unchanged integration of leprosy control into the general health services has become imperative. However, this transition is now hindered by a number of obstacles that were not foreseen at the start of the programme, because they are in measure corollaries of the successful implementation of MDT. Most of the problems that leprosy control is facing in Zimbabwe could have been avoided if instruction in leprosy had been introduced into the curricula of the (para) medical training schools 20 years ago.     

111例I型麻风反应的临床分析

目的：探讨ＷＨＯ／ＭＤＴ方案治疗中Ｉ型麻风反应的发生率,临床特点及治疗。方法：对１１１例Ｉ型麻风反应的发生率,与型别关系,临床表现,反应出现时间及持续时间进行分析。     

麻风联合化疗中发生麻风反应43例临床分析

目的:了解联合化疗(MDT)中发生麻风反应患者的临床特征及相关因素,为麻风防治工作提供依据.方法:收集2006-2020年在全国麻风病防治管理信息系统(LEPMIS)中登记并终审通过的山东省所有完成MDT且在此期间发生麻风反应的患者的相关信息,应用SPSS 23.0软件进行一般描述性统计分析和非参数Spearman秩相...     

Leprosy elimination through integrated basic health services in Myanmar: the role of midwives.

Myanmar is one of the top 16 countries identified by WHO as being hyperendemic for leprosy. Multi-drug therapy (MDT) was introduced in 1988 as a vertical programme and gradually integrated into the basic health services (BHS), achieving 100% coverage over the registered cases by 1995. To achieve maximum coverage of and benefit for patients, both leprosy vertical staff and BHS staff were trained to implement MDT whilst performing routine BHS activities. This included a total of 8615 trained midwives who were mobilized for the nationwide leprosy elimination programme (LEP). They worked at village level in various parts of the country and were willing and able to carry out basic tasks in leprosy management, such as the implementation of MDT using blister-calender packs carrying a month's supply of drugs. This study was performed to assess the workload of midwives and their attitude towards LEP. The authors conclude that midwives in Myanmar show a high level of commitment and reliability, which are essential contributing factors to achieve the current goal of leprosy elimination by the year 2000. Along with the present trend of decreasing prevalence rate, leprosy could no longer be considered as a public health problem at national level by the year 2000 in Myanmar. However, because of its long incubation period, new leprosy patients may arise even after the elimination target is achieved, whilst many other patients may become disabled. A community-based sustainable approach for the post-elimination phase, after the year 2000, will be essential and the contribution of the midwives may be of considerable importance.     

Studies on mode of detection of leprosy in China during the years 1981-1998.

Along with the nationwide economic reform initiated in the early 1980s and the rapid decrease of leprosy endemic after the implementation of multi-drug therapy (MDT), the leprosy programme changed from 'vertical' to 'horizontal'. An evolution in the mode of detection of leprosy cases has consequently taken place. Based on the nationwide registration of newly detected cases, the profile of patients at detection has been studied. The proportions of cases corrected significantly with calendar years in detection by dermatological clinics, contact checks, 'clue survey' and mass survey, showing a significant increase in percentage of cases detected through dermatological clinics and contact checks, and decreases through 'clue survey' and mass survey. Detection of cases through dermatological clinics and voluntary reporting have become the main modes of case-finding during 1997-1998, accounting for 37.3% and 28.6%, respectively, where contact check accounts for only 9.1%. In areas with good dermatological services, a significantly higher proportion (75.9%) of cases was detected through dermatological clinics, where voluntary reporting and 'clue survey' were the main modes of detection in endemic areas. As regards confirmation of diagnosis, the great majority of cases were confirmed by leprosy units, even though they were detected in various other situations. Only 6.5% of leprosy cases were detected and subsequently confirmed by doctors in dermatologic clinics. The present modes of detection and their relation to demographical, epidemiological, clinical factors and health services are discussed. This study emphasizes the cardinal importance of the dermatological clinics in the detection of leprosy cases in China at the present time and hence the need to strengthen the training of doctors in these clinics, while continuously encourage their involvement in leprosy control.     

Causes of death among active leprosy patients in China

We analyzed the causes of death among active leprosy patients in China, to better understand the disease and improve the quality of services, by performing a retrospective study involving 24 provinces of China. Information about patients with active leprosy who were not clinically cured and died between January 1, 2000, and December 31, 2005, was collected by professionals at county levels. A total of 524 deaths were analyzed. The leading cause of death was suicide. There were 86 patients (16%) who died at a mean of 21 ± 19 months after starting multi-drug therapy (MDT). The second and third leading causes of death were cardiovascular disease and organ failure associated with advanced age, respectively. Two hundred and twenty-one patients (42%) died within one year of beginning MDT. The second month of MDT was the riskiest for newly treated patients; approximately 20% of patients succumbed to liver failure, 33% to dapsone (diaminodiphenylsulfone/DDS) allergy, and 27% to renal insufficiency during this period. Among 143 deaths related to leprosy, 37 (26%) occurred within three months of starting MDT. We recommend that newly diagnosed patients should be provided with no more than two months of MDT blister packs.     

Clinical, bacteriological and histopathological study of 62 referral relapse cases between Jan 2004 and Dec 2009 at the Foundation for Medical Research, Mumbai

Sixty two patients with relapsed leprosy seen between Jan 2004 and Dec 2009 were studied using clinical, bacteriological and histopathological parameters. The findings thus obtained were correlated to parameters such as trend and source of referral, clinical characteristics at diagnosis, treatment received, other events during or after RFT and duration between cessation of treatment and relapse. FINDINGS: Referrals per year have doubled since 2006. Most patients were referred by NGOs (58%), followed by Govt. hospitals (16%) and then by GPs (25%); 76% had received one of the WHO - MDT regimens including 16 treated with 24 months or more MB - MDT, 23 with 12 months MB - MDT and eight with 6 months PB - MDT. Of the remaining 14 cases, four had received DDS mono-therapy, seven had single dose of Rifampicin, Ofloxacin and Minocycline (ROM) and four Rifampicin and Ofloxacin (RO) daily for 28 days. The average incubation time of relapse, defined as duration between cessation of treatment and relapse was (SD) + 6-4 years. 59% of patients had positive slit skin smears on relapse. Relapse for the second time occurred in six BL cases including five from group 2 and one RO treated patient and 11/23 cases from group 2 conferred to BT-BB leprosy. Clinical features at diagnosis and on relapse were comparable in 47% of cases. CONCLUSION: All leprosy patients, regardless of their type and MDT regime, carry 'risk of relapse'. A shorter treatment duration reduces the incubation time to relapse. In group 2 (treated with 12 months MB-MDT regime) 11/23 were BT-BB cases and 5/23 (21%) were relapse for the second time, which further supports our earlier documented findings and maybe the efficacy of WHO-MDT regime is poor in a small subset of patients.     

A clinico-pathological study of multidrug regimen in paucibacillary leprosy

Preliminary results of a clinical trial in one hundred untreated paucibacillary leprosy cases with multidrug therapy (MDT) as per WHO recommendation are presented. Out of 100 fresh cases studied 18 had indeterminate, 35 tuberculoid and 47 cases had borderline tuberculoid leprosy. All were given MDT consisting of rifampicin 600 mg once a month and dapsone 100 mg daily for six months. At the end of six months all the cases were evaluated clinically and histopathological examination of lesions were studied. The lesions were still active in 35% of patient clinically and 47% histologically. Complete histological resolution have come across only in 4 cases suffering from indeterminate leprosy. Altogether 65% cases receiving MDT have shown marked improvement to total inactivation. Histologically, lymphocytic infiltration still persisted in 90% of slides examined and nerve infiltration were still present in 64% of cases at the end of six months receiving MDT.     

Disability prevention and management in leprosy: a field experience

Bombay Leprosy Project has conducted operational research into cost effective ways of using therapeutic management for prevention of disabilities (POD). The goal of achieving this are broadly divided as 1) prevention of impairments and disabilities [POID] and 2) prevention of worsening of disabilities [POWD]. About 33-56% of newly registered leprosy patients already have clinically detectable nerve function impairment [NFI], often no longer amenable to MDT. An analysis of 892 leprosy cases treated with WHO-MDT stresses the need to focus attention on leprosy patients having > 5 skin lesions and multiple nerve thickening. Assessment of 454 disabled leprosy patients after 4 years indicated that the compliance for the services offered was good and it helped to improve the disability status in more than 50% of patients. In terms of effectiveness of the services, it was found to be effective in preventing worsening of deformities in hands and healing of trophic ulcers in feet. The methodology adopted has also helped us to develop an operational research model about the necessity to systematize the assistance and support to be given if the services can be routed through a public health facility. Because of the large numbers of leprosy patients with disability living in this region and the limited resources available, the services have to be targeted towards those who are most in need. The major advantage of such community based program is an attempt to eliminate the social stigma in the patients' families and the education of the community.     

Treatment outcome and impact of leprosy elimination campaign in Sokoto and Zamfara states, Nigeria

A Leprosy Elimination Campaign (LEC) was implemented in 37 districts of Sokoto and Zamfara states, Nigeria from 13 August to 30 November 1998. The campaign utilized intensive community mobilization and training of local health personnel to detect hidden leprosy cases. During 8 weeks of case finding, 160,127 persons were screened; 353 new cases of leprosy were detected and placed on MDT; 236 (67%) of new cases detected were classified as MB, 64 cases (18%) suffered visible deformities and 24 patients (6.8%) were children. Follow-up in December 1999 of patients placed on MDT revealed 97% PB and 96% MB cure rates, respectively. Detection of cases in communities led some community leaders to ask for repeat surveys in their communities. Repeat surveys continue to yield new cases. The authors recommend that LECs be maintained for 3 years to accelerate leprosy elimination in the region. The cost effectiveness and impact of LEC in Sokoto-Zamfara are discussed.     

Clinical analysis of multibacillary leprosy patients after 1-year fixed World Health Organization recommended multidrug therapy at Yangon General Hospital, Myanmar

This study included 200 randomly selected multibacillary leprosy cases who had completed 1 year of fixed World Health Organization recommended multidrug therapy (WHO-MDT) without prior dapsone (DDS) monotherapy. The time interval after release from treatment varied from a few months to 8 years. All cases were clinically reviewed in 2006 by comparison with their old clinical records. Reactions, particularly reversal reactions, occurred frequently among patients who had completed MDT within the last 3 years. It was difficult to distinguish relapse cases and late reversal reactions in skin smear-negative multibacillary cases. Based on bacteriological and histological analyses, one patient was confirmed to have relapsed 1 year after release from treatment. The overall relapse rate was 0.5%. No drug resistance mutations were detected by polymerase chain reaction or dot blot hybridization. The present study indicates that it is important to follow up patients for several years after completion of MDT in order to detect possible lepra reactions and relapses.     

Leprosy in HIV infection: a study of three cases

The course of leprosy in patients with HIV infection has been a controversial issue for a long time. It is still a matter of debate whether the HIV status of an individual has any impact on the natural history of leprosy and response to anti-leprosy treatment. We report here three HIV-positive leprosy cases (two BT and one BB) along with their CD4 counts and HIV staging with anti-leprosy therapeutic response. Both BT cases responded well to conventional WHO MDT (PB) for 6 months, whereas the BB case relapsed 3 months after completion of MDT (MB) for one year. However, he became inactive again following a further one-year course of MDT (MB).     

Can the skin smear examination in NLEP be reconsidered?

Slit and skin smear examination is an important laboratory test which was made optional in the NLEP. In a laboratory managed by LEPRA Society, this test was provided to voluntary reporting cases and those referred by the general health service institutions of the area. Total cases tested were 1180, out of which 152 (12.9%) were positive. Of the 152 smear reports, 121 were from Koraput district and constitute the sample for this study. Regarding the spread of site wise highest BI, 56% cases had BI of 3.1+ to 6+. Of the 121 cases, 112 (92.6%) cases completed 12 doses of MDT. Seventy patients, from whom detailed information was collected by personal contact, responded well to MDT resulting in regression of lesions. Out of them, 46 cases had repeat smear showing negative smear in 39% and decline of 81 in the rest of cases. There are 16 contact cases with 2 family clusters. A rough block-wise mapping showed 4 strata with a dense clustering in the urban area where the laboratory facility is available. The probable reasons for uneven distribution of cases and causes for late diagnosis were discussed. The study reflects the leprosy problem in urban pockets which high infection pool. Together these two factors remain unexposed due to winding up of smear labs and pose a potential threat to elimination. The paper also emphasized on the reasons for past failure of the test along with suggestions to revive this facility with minor modifications.     

Leprosy situation in endemic states of India and prospects of elimination of the disease

In India there is a dramatic fall in the prevalence rate (PR) of leprosy, but the new case-detection rate (NCDR) has not been reduced concomitantly. It is the operational efficiency of the National Leprosy Eradication Programme (NLEP) that has led to a significant reduction in the NCDR in Andhra Pradesh and Tamil Nadu. The ratio of PR to NCDR has been declining in these two states and it reveals that elimination could be reached even with the high NCDR level of 3 to 4 per 10000 population, particularly if single skin lesion (SSL) cases are discharged through single dose treatment of rifampicin, ofloxacin and minocycline (ROM). On the other hand, the significant number of cases detected in Bihar and Orissa during modified leprosy elimination campaigns (MLECs) reveals that there are lacunae in operational activities in new case-detection resulting in a large number of undetected cases in the community. Only one-third of the cases are reporting voluntarily. Awareness of leprosy is not adequate to motivate the patients to report voluntarily and complete their treatment, thus underscoring the need for relying on active case-detection so that transmission can be broken and elimination of leprosy achieved. In addition, the influence of socio-economic factors on continued occurrence of leprosy cannot be ruled out. The establishment of a sentinel surveillance system along with a computerized simplified information system to gain in-depth knowledge on the functioning of the NLEP will ensure operational efficiency. In view of this situation, the NLEP should adopt a more realistic approach towards reaching the elimination goal.